Cost-Effective Rehab – Why You Don’t Need Fancy Rehab Programs, with Menno Henselmans

We have discussed several examples of how we can make functional medicine more efficient and cost-effective.  Oftentimes we look to science to help us understand what testing and treatment is not needed and which ones we should focus on.  Today I was very impressed with Menno Henselmans as he outlined how we can do the same thing with rehab for musculoskeletal problems.

In This Episode

Prelude … 00:00:39
Episode Intro … 00:02:41
Strength Training and Rehab Programs … 00:07:06
The Essence of Bodybuilding … 00:09:09
Compound vs. Isolation Movements … 00:13:23
Creating Structural Balance … 00:15:37
Simplify Your Strength Training … 00:20:43
Ergonomics and Posture … 00:23:34
Building a Healthy Foundation … 00:24:56
Excessive Screening … 00:26:32
Flexibility: Compound Exercises vs. Stretching … 00:28:58
Rep Ranges and Hypertrophy … 00:35:44
The Misconception of Getting “Bulky” … 00:40:51
Strength Training and Range of Motion … 00:43:58
Improving Flexibility … 00:47:31
Getting Started with Bodybuilding … 00:49:05
Episode Wrap-up … 00:51:32

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Prelude

Dr. Michael Ruscio: Hey, guys. This was an impressive interview with Menno Henselmans. Gosh, he really impressed me with the level of knowledge about things regarding rehab, strength training, some of the kind of sacred cows of the fitness and rehab industry that maybe are no longer relevant, like requiring fancy rehab programs to help someone recover from pain or requiring plans that try to balance out muscular imbalances that are highly specific to said imbalance, or that stretching programs need to be used to rectify imbalances before strength training is used.

And again, I was just really impressed with his practical nature, his evidence-based nature, and how he appears to be doing something very similar in the fitness space to what I’m doing in kind of the health and medicine space, which is looking at some of the current beliefs, filtering those through what contemporary evidence shows, and abandoning the recommendations that are no longer factual or relevant and working to make things simple, cost-effective, and practical.

So this is definitely a call I would recommend listening to, because it was very insightful. And there are a lot of great takeaways that I think can really help to consolidate and simplify whatever you’re doing with regards to your own exercise and fitness plan. Or if you’re providing counsel for people on how to increase their strength, their stability, their muscular balance, or helping them try to rectify pain, then I think this might be very helpful. So let’s go ahead and jump in. All right. Thanks.

Episode Intro

Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today, I am here with Menno Henselmans, who wrote an article actually now a couple of years ago that went out in the Paleo f(x) blog. Really loved the article, and I’ve been trying to connect with him for a while now. But he kind of hops around globally, so it’s been hard to coordinate time zones. But finally, we’ve got him here to discuss what I thought was a fantastic article that goes into a number of things regarding why bodybuilding is healthy. And we’ll detail this. It’s not maybe the stereotypical definition of bodybuilding.

And one thing in particular that I really loved was how he showed that simple strength training can be as, if not more, effective than very fancy rehab programs. So, a lot I want to dig into, and, Menno, thanks so much for taking the time to speak with us today.

Menno Henselmans: My pleasure, Michael. It’s good to be on the show.

DrMR: You wrote, like I said, a pretty fantastic article. And let me pull it up here so I can give the right title. It was entitled—we’ll put the links for this in the transcript—“Four More Reasons You Should Be Bodybuilding.”

Before we jump into some of the details, which I’m, admittedly, excited to jump into, can you tell the audience a little bit about your background?

MH: Sure. I didn’t start off as a very traditional career path for a bodybuilding coach. I started off working as a business consultant and my education was actually in behavioral economics and statistics at Warwick and University College. So I was set for a much more corporate career trajectory, but I quickly realized that that wasn’t what was going to make me most fulfilled in life, and it was more the prestigious career path that my parents and my upbringing.

So at some point, I started working towards a career in fitness. I did it gradually. It wasn’t a very, boom, I quit my job and now I’m going to coach people. I did it very gradually, been going great so far. That was five years ago now. Business has grown immensely. I now have a whole research team with five people working for Bayesian Bodybuilding.

We’ve got our own fitness education, our certification business. I do full-time online coaching, like one-on-one with clients, the more experienced kind of people like bodybuilders, power lifters, models. But also, lay individuals that want to take their strength training and their physique to the next level. So usually, the people I work with are commonly people that are on a high protein diet. They know the importance, the basics of what is a carbohydrate, what is fat, that kind of stuff.

And they do strength training at least three times a week. So that is like 80% at least of my population that I work with. And one of the things that I found as a coach, I have a lot of experience with—and I generally don’t flaunt experience because I’m very much a man of science and not “my clients say this” or all these anecdotes. It’s always not easy to say this, but one of the few things I think that as a coach you do get a lot of experience with is injuries.

Because in my kind of clientele, everyone is pushing the envelope. People are bound to get injured. And there is not that much scientific research on injuries, especially not this kind of injury that is not simply due to a gross muscle weakness, something like that. And that is something you really learn to—you see what works and what doesn’t in getting people back to strength training.

DrMR: Yeah, I think it’s clearly evident, at least by the way that this article was written, that you’re a man of science, as you said, and you have probably some research team behind you, helping you, because the references were impeccable. And when I see a comparative clinical trial, I get really excited because I’m sure the audience is used to me harping on the fact that we sometimes have this erroneous tendency to cite mechanism or observation, which is a part of scientific evidence, but it’s not very strong scientific evidence. So when you were citing, for example, this comparative trial that I want to come to more fully in a moment, it got me really excited.

Strength Training and Rehab Programs

And also, I should mention that in my experience from back when I was heavily involved in musculoskeletal work, when I was working as a personal trainer and also doing rehab while I was getting my degree in exercise kinesiology, I was also pursuing a lot of outside education. I was telling you before we started recording I was certified as a C.H.E.K. Practitioner. And I went very in-depth into the world of exercise rehab. And it was something I incorporated into my offering when I was working with clients in this kind of setting.

And one of the things I noticed fairly early on was that there seemed to be this excessive assessment. And there’s this old saying, which is “if we’re not assessing, we’re guessing,” which, I suppose, is true compared to if you’re doing zero assessment. But I think all too often what happens is we are doing way too much assessment to the point where we are no longer being effective, and we’re certainly not being cost-effective.

And when I saw this first study in your article that—let’s see here, this was by Saner et al, 2015, and they essentially compared fancy rehab programs to a general strength and conditioning program in patients with low back pain. And as you said here, they followed patients for a year, and in every measure point, the general strength training program was just as effective as the physical therapy program at relieving pain and disability.

So, that, I thought was very compelling, and it certainly reflected my personal experience. And I’d like to start within this topic of why bodybuilding can be healthy with more expansion on your thoughts about how we may not need to be so meticulous in our assessment and fancy in our rehab prescriptions and how that a general strength training program may be able to provide just as much benefit.

The Essence of Bodybuilding

MH: Yes, absolutely. I think one of the first things I should clarify is that when I’m talking about bodybuilding, I don’t necessarily mean competitive bodybuilding. So I don’t mean getting oiled up and tanned and posing on stage.

DrMR: And I’m you glad you made that distinction, because that’s one I wanted to make. Yeah, I think that’s really important for people to understand. Probably when they hear bodybuilder, they picture some huge guy who’s been spray-tanned and oiled up. But how would you describe it—more of a working to have a healthy body composition? And you could not be necessarily big, but be smaller and just toned and fit and still be bodybuilding to that endpoint.

MH: Yeah, the reason I actually started off with the name Bayesian Bodybuilding is that I know that it’s a very stigmatized name and term. But I kind of want to push people on the facts that bodybuilding in essence is just increasing muscle mass and decreasing fat mass. That’s it.

And there are degrees to how much muscle mass and how little fat mass people want to have. And if you’re going to be a competitive or a pro bodybuilder, then you want to have a lot of muscle mass and very little fat mass. But most individuals in the gym, they want the same thing, maybe not to the same extent. But I think it’s pretty safe to say that the vast majority of men at least want maximal muscle growth in all body parts if they’re natural. It’s not like you’re going to wake up as Ronnie Coleman one day.

Most people that want to look toned or athletic, they want the same thing as a bodybuilder. Maybe they don’t want 20 kilos of muscle, but if you can build the 5 kilos of muscle that you want to look toned or fit or athletic, however you want to describe it. Objectively, it simply comes down to, say, 5 kilos of muscle gain with 5 kilos of fat loss, then you can do that on an optimized bodybuilding program in, say, six months. Or you can do it in six years doing Pilates and yoga and whatever.

That is basically just what I consider to be the foundational element of bodybuilding: increasing muscle mass, decreasing fat mass. And the core tool you use for that is strength training, strength training program.

And I think, with respect to injuries, you also basically want to do just that. Most people, most clients, they’re overweight, suffer from chronic inflammation, especially really obese clients where the weight literally poses compressive forces and stress and the impact of walking and the like actually pose injury risk. Then really what you want in a client is just to strengthen most of the muscles surrounding the injured body part and lose fat, primarily increasing strength.

And the best way to increase all-around strength, because most strength is very much a neural phenomenon, not really morphological. So it’s mostly that you learn to—strength is mostly becoming better at a certain movement. It’s even in our language that, for example, a power lifter is strong. We say a power lifter is strong.

When really, the accurate language should be that a power lifter has certain strength, or, even more specifically, a power lifter is someone that is good at bench pressing, squatting, and deadlifting. Because strength does not necessarily translate that linearly for one movement to another, especially if it’s a different force factor, a different movement pattern.

So when you have someone that’s injured that is not engaging in strength training, almost always what you want to do, regardless of diagnosis, is just to strengthen all the surrounding tissues. And that is basically what a bodybuilding program does. So that indeed is also what a lot of studies, or at least a few studies—there is not that much literature—have done and compared these exercises, special rotator cuff work, specific lower back exercises. If you compare those to people doing deadlifts or squats, shoulder presses, rows, pull ups—if they’re strong enough for those—then often you get the same net results.

Compound vs. Isolation Movements

DrMR: Now, when you’re saying bodybuilding—and I’m pretty sure I’m hearing this, but I want to just ask this question more so for the audience—you’re not necessarily meaning doing some of these highly specific exercises like a pec fly or quad extensions. You’re talking more of, I guess you could say, your Arnold Schwarzenegger era old-school bodybuilding, just like you said, squats, deadlifts, bench press.

Are you finding that these compound movements with free weights are what’s really helpful and are you shying away from some of these highly targeted—here’s the machine and the machine highlights your shoulders. You do this one isolated movement to target your shoulders sort of isolation movement.

MH: I think for rehab purposes both have their place. But in most programs, compound exercises that involve multiple joints, multi-joint exercises, should be the foundation of the program. And when you are injured and you can’t perform those, for example, during a shoulder injury, if you can’t perform overhead presses, bench presses, rows, vertical pulling exercises, then those are definitely preferable.

For example, a high row or any kind of row exercise generally involves all the musculature and then some that you would target with, say, a rotator cuff shoulder external rotation exercise. And it’s actually quite ironic that isolation exercises sort of have a mixed reputation in that on the hand isolation exercises are seen as nonfunctional. And they won’t do anything, for example, people might argue for functional strength.

Whereas, on the other hand, most physiotherapists prescribe almost nothing but isolation exercises to their clients, for example, during shoulder rehab. Or to target their lower back, they will do Supermans or back extensions or something, instead of, say, a Romanian deadlift. So I think both have their place, but, yes, compound work has the preference if you want to teach people to become stronger in more general movement patterns.

Creating Structural Balance

DrMR: Now, are you finding that there is a particular ratio? And I’m thinking here just to try to give people general goals to strive for. Are you finding that people should be doing a certain ratio of pushing to pulling movements? For example, bench press and shoulder press to things like pull ups and rows, or potentially things like squatting to deadlifting to maintain balance in some of these kind of, I guess you could say, broadly flexor and extensor chains. Are you finding certain ratios there are generally important or helpful?

MH: There needn’t really be a ratio. I wrote an extensive article on structural balance theory, for example, that was pioneered by Charles Poliquin. And I basically concluded from a variety of angles that your body does not really care about structural balance. Most of what happens in a muscle group is local. The very process of muscle growth itself is very much a regional, a local process.

I always say what happens in a muscle stays in a muscle. It’s not entirely true. There are some systemic factors it seems. But we can already explain the majority of muscle growth simply from a few basic local factors that we know and mechanical tension being a key driver of muscular adaptation.

So I don’t think you really need to be concerned with specific ratios. But what a bodybuilding program does and what I think you should also do generally in rehab is to strengthen all the relevant musculature. And you basically want to maximize muscle growth, or, in the case of injury rehab, the muscle growth is not directly the goal. But the program design is very much the same: you want to strengthen the tissues. But it’s basically the same program that will achieve that generally.

So you want to do that for all muscle groups. For example, for the deltoids, you want to strengthen the posterior deltoids and the front deltoids, which means that since they are similar muscle groups, they will require the same training volume to have the optimal training adaptation, which means you want to give them the same training volume. It’s not because you really want a certain ratio. You can have a very different exercise selection that might have very different ratios but still result in the same training volume for those two muscle groups and result in very similar training adaptations.

So I think that is more the angle that I would push for than looking at certain ratios. The problem with ratios is that they are very, very susceptible to training effects. So you might, for example, a common ratio for knee health is that leg extensions and leg curls should be approximately 1:1 in strength. But this varies enormously per machine. If you have a machine that has an additional cable pulley on one of the machines and not the other, for example, you can have a twofold difference in the resistance that you put on the machine even though the actual intrinsic work done by the muscle might be the same.

If you have one individual that has been doing nothing but squats and leg presses and compound exercises for his quadriceps and the other individual has been doing a lot more leg extensions, isolation work, then the person that has the experience with the isolation work will have a lot more developed leg extension strength, even though they might have similarly developed and similarly sized quadriceps muscles.

So any use of ratios should be very, very rudimentary and regarded as a very rough guideline I would say.

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Simplify Your Strength Training

That makes a lot of sense. As you’re making those comments, a few things shoot through my mind. Of course, Charles Poliquin is a pretty well-known name in strength and conditioning. And for the audience, if you’re not familiar with Charles Poliquin, he’s kind of a giant in strength and, especially, he trains a lot of professional athletes, a lot of Olympic athletes. And it’s funny that you checked into some of the structural balance theory, which is Poliquin’s theory of needing to have these certain ratios between muscle groups for optimum performance.

And thinking about Poliquin and also thinking about Paul Chek, two gentleman that I learned a lot from early in my career, and I’m certainly very grateful for everything that they’ve done in terms of educating myself, educating others, contributing to the field. But I do think that the next generation of providers, whether it be in fitness as yourself, Menno, or more so in health medicine on my side, the next generation is really taking these concepts, standing on the shoulders of these gentlemen and trying to better the work.

And I think a lot of that betterment is going to be consolidation of the message or the assessment or the recommendations and really trying to increase efficiency and decrease the frivolousness. I’m reminded of Ryan Flaherty, who was recently interviewed on Tim Ferriss’ podcast, and I thought he did a really great job of, again, making this statement or this argument for much more simplified strength training.

And he wasn’t making these highly meticulous recommendations for what he was talking about in one component of the interview, which was sprint speed. He was simply saying that if you can achieve a strength ratio of—I think he was saying—three times your bodyweight. If you can hex bar deadlift, I think he said 3.2 times your bodyweight, that gets you to an Olympic level athlete level of sprint speed or it correlates to that.

And he did not find that you needed to have these highly specific ratios of quad extension strength to hamstring flexion strength. And I see the same thing in my area, which is more digestive health and not needing to have these super meticulous tests or super meticulous treatments. So I think this is where the field at large is going.

So I’m really encouraged by what you’re finding and by what you’re saying. Do you have any familiarity with Ryan Flaherty or his work, Menno?

MH: No, not really.

DrMR: Okay, yeah. Because you guys are saying some similar things, so it’s nice to hear these same sorts of lines of thinking reinforced by different authorities.

Ergonomics and Posture

There’s a couple other articles I wanted to just get any input that you may have from your article. You mentioned that Anderson et al, 2008, essentially compared the effectiveness of strength training to health counseling and ergonomics to improve posture.

And essentially, the finding was that strength training was more effective at relieving pain in the shoulders and neck. And also, it was easier for the participants to stick to. This may be a tough pill to swallow for some providers who place a heavy stock on ergonomics, but it’s not necessarily a bad thing, because if we uncover evidence that’s showing that there may be a better or a different way of doing things, then we can look at that one of two ways.

One, something that we don’t want to believe and we can stick our head in the sand. Or, two, we can update what we’re doing and become more effective. So I would look at this as hopefully something that would be welcomed, even if you are someone who places a lot of emphasis on ergonomics. And it doesn’t mean it has to be either/or. It can be both/and.

But on that note specifically, would you say there’s a predominance of data showing that strength training outperforms ergonomics in addition to what this one article showed?

MH: I would say so, yes. I think that strength training is the foundation, and then you might want to supplement that with specific ergonomic work.

Building a Healthy Foundation

MH: Basically, if I was to summarize my article, especially for more the general population at large, then I would say that the vast majority of problems—and you also touched on diet. I think it’s the same thing there. Most dietary issues, gut issues, IBS, inflammation, diabetes, I experience the same thing in my clients.

What you want to do with almost all clients is you get them on a healthy, whole foods-based diet, and you have them perform strength training. You get them to a healthy body fat percentage. You get a healthy level of muscle mass, and you get them strong at the basic compound exercises.

And that takes care of the vast majority of problems. I’ve had clients that I didn’t do any specific counseling for it, but they told me, “You fixed my hay fever. I haven’t had hay fever any more on this diet.” Or IBS or certain immune conditions. People have gone off their diabetes medicines. You don’t really have to do anything specific for that. They’re just the general foundations of getting someone healthy.

And the vast majority of ergonomic postural problems or basically any kind of problem that general public has is often caused simply by muscle weakness, not a ratio of weakness, not a specific kind of muscle that is the culprit. There is just all-around muscle weakness. The tissues are just weak. And you want to strengthen those, and that takes care of the problem.

And you want to put them on a healthy diet, and it doesn’t even matter specifically what kind of problems they have, that should always be the foundation.

Excessive Screening

And you also touched on excessive screening. There is now a large amount of literature that, for example, the functional movement screening, which was all the hype in the functional training crowd, really doesn’t predict much. So you might get someone, you screen them, and you think they have this dorsiflexion mobility limitation or maybe they have a certain off ratio on their symmetry in thoracic extension mobility.

Really, these things, they are so specific that you test. Everyone’s going to have something wrong with them if you test them on 20 of these things, and you have these arbitrary benchmarks that people should be able to touch their toes and people should be able to do this and this and this movement. And you can get someone that does—an Olympic level squatter for example.

And you have them do these weird squat tests, I know some people that because they are quite strong and their muscles are stiff, stiff in a good way, as in able to resist resistance. And I actually have the same thing to some extent. They have a lot of difficulty getting into a deep squat position with an empty barbell. When you put some weight on it, their squat form is perfect.

So if you test them with an empty barbell, which is often done with these kind of tests—they don’t use a lot of weight because it’s unsafe—you might conclude that they don’t have the mobility and their squat is horrible. Whereas, really, they can squat quite well with 400 pounds on their back. So there isn’t really a problem. They don’t have any symptoms. There is no pain. There is no loss of range of motion. There is no strength deficit.

These tests, they’re not practically relevant often. Like I said, the general solution, regardless of the problem, is generally to just get people healthy. Get them strong with the basic movements. Put them on a healthy, whole foods diet. That is the solution to 80% of problems. And if that doesn’t solve it, then probably you should start screening for more specific problems.

DrMR: Gotcha. Yeah, it’s a very interesting note that you make that muscle tone that sort of, I guess, pseudo-resting muscle tone that we may sometimes look at as tightness may actually be protective. And it’s protective because, of course, that muscle tone to some extent will protect the joint. And you may get a non-representative assessment if you’re using something like a non-weighted bar. That’s actually a really interesting point.

Flexibility: Compound Exercises vs. Stretching

So what about the perspective of metabolism? Actually, let me take one step back, because there’s one other article that you mentioned that I should maybe just cite while we’re on the topic of flexibility before we move to the issue of metabolism. And I think you’re actually citing two articles here, but compound exercises were as effective at improving muscular balance as were an overall stretching plan this other article cites.

So that reinforces what you’re saying, which is even strength training may add to someone being flexible more than traditional stretching. This actually comes back to something I’ve heard Chek say, to his credit, which is sometimes tightness is an indication of weakness. So muscles are tight because they are weak, not because they need to be stretched. Is that something that you’ve also come across?

MH: Yes. I would generally say that tightness is an adaptation by the body to resist the joint being put into greater levels of extension or flexion, whatever the case may be in the tightness. Usually it’s stretching of the joints. And that can have numerous causes. One may be simply that it is advantageous for a sprinter, for example, to be tight so that leg extension relation, for example, changes so that the sprinter can produce more force within the range of motion used during sprinting. So it can be a functional adaptation.

Often, in the case of injuries in my experience, it seems to be more of a protective mechanism that the tightness is a signal which you often get, for example, if you strain a muscle. It will feel tight. That, I think, evolutionarily speaking is a protective mechanism to prevent further tearing of the tissue.

So basically, stretching is the last thing you really want to do. A general conclusion I have come to in stretching—I’ve written a few articles on stretching and also touched on that in that series on Paleo f(x)—that stretching does nothing for morphology. So the actual structure of the muscle tissue, the muscle fascicle length, how long your muscle is, stretching does nothing for that.

There has been one study that actually found an increase in muscle length, but you are talking about very extreme weighted stretching protocols that are gruesome, put people in a stretch position with weights and then increase the stretch every 30 seconds for, say, a period of four minutes. That is way beyond even the most hardcore forms of yoga.

So within the practical constraints of a normal stretching program, regardless of whether it’s yoga or whatever it is, you’re not actually going to make your muscles any longer. The only adaptation that really seems to occur chronically is that you teach the nervous system to basically improve neural stretch tolerance, as it’s called. It’s very similar to just an analgesic effect, just numbing the pain, increasing pain tolerance. You just teach the nervous system that it’s okay to lengthen that muscle in that movement pattern to a greater amount. So it’s entirely a neural mechanism; it has nothing to do with muscle length.

Whereas strength training can actually increase muscle length. You can increase muscle fascicle length by putting muscles under a large amount of tension during eccentric muscle contractions, so a contraction where the muscle is lengthening. And then, as an adaptation, it will actually increase muscle fascicle length. And that is part of a certain type of muscle hypertrophy. You can have an addition of sarcomeres in parallel or in series.

So that is a case where very counterintuitively people think that you should stretch and that will make you more flexible. But it’s just a neural mechanism. It’s just your body teaching a trick that you can perform a certain movement; whereas, there is no structural adaptation taking place. So again, the foundation I think should be strength training.

And then, say, if you’re doing the things I work with in, for example, during the back squat position, you have trouble getting your arms under the bar. That is something you could stretch for. It’s a very specific problem. You can do very specific stretching to get your body into that position.

Or for the front squats, if you want to use an Olympic clean grip and there is not enough flexibility in the wrists, you can do stretching for that to put your body into that specific position. But if you’re just stretching your hamstrings just because, then you’re not really going to achieve anything. You get better at stretching, sure.

But it’s going to have very limited functional carryover to any kind of other task. Especially if you’re doing static stretching to carry over to a dynamic task is going to be very limited. And there have been several studies that actually found that this carryover from both stretching and many of these functional exercises, Bosu ball stuff, that kind of thing, has very little carryover to functional movements.

Strength is highly specific to a certain movement pattern. So heavy compound work that just gets you strength in all planes of movements, in all kinds of force factors by increasing muscle size, because that is the only thing you can do to a muscle or a body part to actually make it stronger in any kind of movement pattern, increase the size of the muscle fibers because regardless of directionality of the force that needs to be applied, a bigger muscle always has a higher force potential.

So again, we’re back to the foundation being just heavy compound work.

Dr. Ruscio Resources

Hey, everyone, in case you’re someone who is in need of help or would like to learn more, I just wanted to take a moment to let you know what resources are available. For those who would like to become a patient, you can find all that information at drruscio.com/gethelp.

For those who are looking for more of a self-help approach and/or to learn more about the gut and the microbiota, you can request to be notified when my print book becomes available at drruscio.com/gutbook. You can also get a copy of my free 25-page gut health eBook there.

And finally, if you’re a healthcare practitioner looking to learn more about my functional medicine approach, you can visit drruscio.com/review. All of these pages are at the drruscio.com URL, which is D-R-R-U-S-C-I-O dot com, then slash either ‘gethelp,’ ‘gutbook,’ or ‘review.’ Okay, back to the show.

Rep Ranges and Hypertrophy

Now, one thing I’m curious—and I’m thinking about more specifically the women listening to this, who may be saying, “Well, I don’t want to get bigger.” Now, we have different types of muscle fibers that are more or less prone to degrees of hypertrophy. And please, correct me if I’m wrong, because some of this is really patchy, going back many, many years.

But I believe if you’re training at a somewhat heavier load, maybe six to eight reps or even a little bit less, you are more prone to get the, I believe it’s, the type 1A ,and I may be flopping the type 1A and 1B, but the type of fast-twitch muscle fibers that are not highly prone to hypertrophy. So what I’m wondering—if you agree with this—is if you train at the right weight level or the right intensity of using 10-12 reps compared to maybe six to eight reps or less, you may be able to get some of the muscle hypertrophy benefit, but do it in such a way that you’re not going to be prone to get a very robust hypertrophy benefit.

I believe it’s the type 2A muscle fibers that, if you’re using a classical application of like 10-12 reps with your traditional bodybuilding, those types of muscle fibers are much more hypertrophy prone and would give you more of a mass gain. So I’m reaching and drawing some inferences there a little bit, but would you say that may work? And if not, what would you suggest for women who are looking to get some of these benefits but looking to mitigate how much muscle they put on?

MH: It is true that the more fast-twitch your muscle fiber the higher its growth potential, with type 1 having less growth than type 2A and type 2B having the most potential. A recent review by one of the researchers on my team, that is still in the making, actually concludes that the growth difference isn’t that high. It used to be said that it’s like twofold. It appears to be more like 20-30%, generally.

It also appears that the ratio of different muscle fibers across a wide spectrum of repetition is about 3-20, maybe even 30, is quite similar. So you cannot really target a specific type of muscle fiber to a large extent at least. You can maybe fine-tune it a little bit, but then you’re talking about the 1% fine-tuning for advanced bodybuilders.

DrMR: Right.

MH: For a woman that doesn’t want to get bigger, there is not going to be a big difference in the muscle fiber type growth rates or even, in contrast to a lot of earlier research and conventional bodybuilding wisdom, total muscle growth rates. As long as you’re going to muscle failure, to complete momentary muscle failure or at least very close to it, then it doesn’t matter that much whether you’re doing sets of six or even 20.

As long as you are exhausting the muscle fibers, then they are going to grow. And you can do sets even up to 30. I think 30 is a good practical maximum that I often use. Beyond that, you may get reduced growth, especially with compound work where it becomes cardiovascular exercise. But it’s actually quite similar. So really something over the last few years that research has found in several studies now. There’s a large spectrum of rep ranges that can produce robust hypertrophy.

DrMR: That’s very interesting, because it was kind of a sacred cow of a lot of the more, I guess, academic and bodybuilding literature was that if you had a certain rep range, which also indicates or dictates your intensity, you would either have more or less hypertrophy.

So what you’re saying is that’s been somewhat disproven, and now what’s being shown is, I guess, you said anything underneath about 30 reps will produce a somewhat comparable hypertrophy change.

MH: Yes. The idea in bodybuilding circles was that there is this magic or the bodybuilding rep range, which is generally about six to 12 reps people would say. Some people would say up to 15, and some people would start at five. It’s about six to 12, depending on who you ask, would provide the ideal combination of mechanical tension and metabolic stress or time of retention or it’s the right positional strength in the continuum, whatever the rationale was.

It doesn’t seem to matter. As long as you’re exhausting the muscle fibers, then you can get comparable growth rates across a much wider spectrum of ranges. And even very high intensity work, as long as total volume is high enough, can be equally effective or even more effective at producing hypertrophy.

There’s one study that found that a similar volume of high intensity work—sets of three, I think it was—produced more hypertrophy than sets of I think it was eight or 10. And that was in quite advanced lifters where probably the benefits of higher intensity work are more pronounced. But most studies find no difference, and there have been quite a lot. I think there are probably more than 10 now.

The Misconception of Getting “Bulky”

DrMR: That’s really great for me to know, because it’s nice when some of these concepts are either proven or disproven. And I wasn’t aware of that. That in and of itself was worth the price of admission for me.

MH: Right. I think for women the key issue really often is if a woman says to me, “I don’t want to get bigger,” I generally tell them this: one, truthfully, probably you do want to get more muscular. What you want to do is you want not to increase total volume of your body currently. Most of your volume is fat.

So most women that say they are getting too bulky or whatever, they’re not too muscular. They are too fat. There are certainly exceptions and some women are really muscular, but especially general population where you’re not talking about a woman that easily squats 80 kilos or something, then probably her thighs aren’t too muscular. They are too fat. So the solution is fat loss.

And you can actually get quite a large amount of muscle growth occurring to keep total thigh volume similar or even have it decrease while still having muscle growth occur. So that is a very big first thing to correct. There are a lot of women who will say they are afraid of getting too bulky at their habitual body fat percentage, which that will include a lot of overweight women and women who are close to it.

When you’re talking about women in the 15-20% body fat percentage range, so the athletic range, then that percentage decreases dramatically.

DrMR: Gotcha.

MH: So that is number one. And I think it’s also important to inform them that you have to fight tooth-and-nail for years to put, say, five, 10 kilos of muscle on your frame. It’s not easy. It requires very hard work, and it doesn’t occur overnight. So even if you do get too big, which is what I say—I call that a pure luxury problem—you just stop training the muscle and it will decrease in size. It’s that easy.

So most women really don’t need to be that concerned with it. There are certainly a lot of women that in my clientele, for example, I have been strength training for quite a while, and they have a foundation of upper body strength and that is sufficient to keep them healthy and functional. And then, you don’t want to have them do more biceps curls or stuff to actually target further arm growth.

Really, they only want more glute mass. Typically, my clients are what I call the bikini physique. They want bigger delts and large glutes to give them that X taper and that bikini body basically, wide or relatively wide shoulders. Not muscularly wide, but an X taper and a big booty, which is now all the hype.

DrMR: Those are some great points, and hopefully those will be helpful for women who may be grappling with some of this.

Strength Training and Range of Motion

DrMR: And just one thing really quick to your earlier point, strength training and flexibility. I was getting some hip tightness for a while. One thing I did that I felt helped a little bit was get a sit-to-stand desk.

As you were saying something, I really connected a dot, which was as I was reflecting back, I had gotten out of the habit of really doing much in the way of squatting or deadlifting because I was playing a lot more soccer. And I figured, well, I’m getting a lot of lower body with soccer. And I don’t want to overload my lower body. So for a number of months, I was not squatting. I was not deadlifting. I was not doing walking lunges, which I usually do.

And I am now back into those, and I actually noticed that I get less popping, less tightness in my hips, even though I’m probably stretching them less now because I’ve been doing more squatting, more deadlifting, and more lunging. So at least in my reflection and in some of my experience, I have found that to be true. And, again, that concept being that strength training may be better for flexibility and range of motion than maybe just your traditional kind of stretching program.

MH: Yeah, to give some insight into my background, because many people think because I coach bodybuilders, I read a lot of muscle mags and I did typical pro bodybuilding program. That wasn’t at all what I did first. When I got into fitness, I was very much into health and postural improvements.

So I did all the functional training stuff. And I did all the strength ratio, push-pull kind of programs. And it was heavy strength training, but I spent more time stretching in some of my programs than I did strength training. And I’ve done all the foam rolling work and all these corrective exercises, shoulder external rotation stuff.

And really, what I’ve found is that it doesn’t do much at all. I could stop doing all of that additional stretching and foam rolling and specific shoulder external rotation exercises and it wouldn’t affect me at all. It didn’t decrease my injuries. It didn’t affect my range of motion during exercise. It really didn’t change anything at all in practice.

In fact, I did all the stretching there was and I couldn’t get my squat below parallel, and I’ve had, by far, the best experience in getting it to a very clean deep squat groove when I don’t do any other kind of stretching. I just do a lot of squatting. And I found that in a lot of clients that by just squatting and doing strength training movements, you allow the natural adaptation of flexibility and stiffness in the right muscles to occur, which makes it a lot more smooth.

And doing a lot of stretching can actually interfere with getting that, because a large part of getting into a deep squat and many other positions as well is not just flexibility. It’s a lot due to stability, because most people can get into a deep squat position. Their body can literally, physically be put in that position. You get them lying on their back, you can put them in that position. It’s not the tissue length. It’s just not the issue.

So the issue is when there’s weight on their back and they have to maintain that position under load. Then it becomes a problem. So really, it’s not an issue of flexibility. It’s generally an issue of stability, strength, and developing the right stiffness.

Improving Flexibility

DrMR: Gosh, and you know where I can see this being so helpful… I know some trainers will not progress someone to doing things like squatting or deadlifting until they achieve enough flexibility. And this completely turns that on its head, where you may be struggling to get someone more flexible because the problem may not be a lack of stretching. The problem may actually be a lack of stability and a lack of strength.

MH: Exactly. And I think many of these curriculums of most popular fitness education programs they do that indeed. They do the overly conservative.

DrMR: Right.

MH: What seems to be the safe course of action starts with bodyweight, and then do goblet squats, and then maybe do box squats or lunge or whatever, and then start squatting. In my experience, I’ve found that if you have them do one good session with qualified personal trainer, they can get squatting within one session, maybe the next session. And they just start progressing faster two months earlier.

There’s no benefit at all—I’ve never seen a person that couldn’t get into a deep squat before and you have them do all this other stuff, all this stretching, and then they try to squat and boom. It just happens. They’re now in a deep squat. No. Often you do all of that mobility work and then you test the squat, and they still can’t squat.

DrMR: That’s a good point. Well, hopefully, that will be helpful for people who are working more in the kind of rehab and musculoskeletal setting to maybe skew some of the way they approach some of their programming.

Getting Started with Bodybuilding

Last question for you, and there may not be a great answer to this. But just wondering if you have any simple takeaways for people. In terms of if they’re looking to get started, is there a core set of simple recommendations for them to start on a training program?

MH: If you want to start strength training, I think it’s good to cover all the basic big movement patterns. From an injury prevention perspective, I think it makes sense to think in terms of movement patterns. From a bodybuilding perspective, I don’t think so. But for a beginner, it’s moot anyway. They just need to get strong at the basics.

So you get them on a program that has a vertical pull, like pull downs, chin ups, pull ups (if they’re strong enough), maybe horizontal pull ups, well, like rows. I’m not really a big fan of those, but fine for a beginner. It won’t all matter that much. Get them to do Romanian deadlifts. I’m a much bigger fan of those than deadlifts, because they have more range of motion for the posterior chain. It will increase hamstring length more, for example. It’s also a lot safer because it’s a lot easier to keep your lumbopelvic complex and your back in its neutral position, which creates even amounts of shearing stress on the spine.

Have them do squats, whether it’s front squats, high bar, low bar. It doesn’t really matter. Just pick a squat they are comfortable with and they can do and get them strong at it. Horizontal pull-like bench press or horizontal press-like—push-ups are actually really great to start with from an injury prevention perspective I think. Also a big fan of cable chest presses. Any kind of movement that has the scapulae in a position to move freely in contrast to say bench presses.

For injury prevention and all-around strength, that, in my experience, is a lot safer. And vertical press. They’re really stigmatized, but I think that reputation is largely undeserved in individuals that don’t have a genetic predisposition because of their shoulder structure. Military presses or dumbbell overhead presses are great to develop overall shoulder musculature and strength.

So if you do a program with those basics, that is where you should start.

DrMR: That’s great. And just for people regarding the chest press, you’re recommending, I’m assuming, someone do that from standing so that their back isn’t pressing against a bench and fixating their scapulae. Is that how you mean that?

MH: Yeah. A standing cable chest press, and then when you get too strong that the weights will pull you out of position, then you do it in a semi-kneeling stance.

Episode Wrap-up

DrMR: Great. Well, Menno, this has been a fantastic call. I am impressed with your dedication to being evidence-based and just practical. And I don’t say that often.

MH: Thank you.

DrMR: So definitely a hat-tip to you, and would definitely love to have you come back on at some point to talk more about the nutritional side, macro cycling calories, and all that. And I’ll definitely follow up with you on that because, again, this was a great call. And I’m sure people will get a lot out of it. So thank you so much again for taking the time.

MH: My pleasure. It was great to talk to you, Michael.

DrMR: Awesome. You too, buddy. Thanks.